Provider Demographics
NPI:1700121597
Name:SULLIVAN, ANN MARY (LMFT)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 CRESTMOOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969
Mailing Address - Country:US
Mailing Address - Phone:530-513-4492
Mailing Address - Fax:
Practice Address - Street 1:955 ELLIOTT ROAD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969
Practice Address - Country:US
Practice Address - Phone:530-513-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALICENSE#25875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist